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APPLICATION TOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION MACHADQ, INC. 1601 E, HAZELTON AVE. , PHONE (209)468-3420 247 N.Jacktone Road r, P O BOX 2009, STOCKTON, CA 95201 Stockton, California 95215 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address AZIQQ ---Xr_"- /�G�/L n- r C Q City 1 Lot Size/Acreage IJ Owner's Name v' 2L*? Address Tf�� phone i Contractor Addres s G Y90� License No. 4d Phone a TYPE OF-WELL/,P.UMP:-- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ ' t PUMP INSTALLATION ❑ SYSTEM REPAIR ��'` OTHER ❑ Monitoring.Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE z '" F-. ,4 'FOADATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TNPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca pia, of Well Excavation Dia. of Well Casing (SYDomestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications Cl Public _A is°Other 171 Delta Depth of Grout Seal Type of Grout 11-trrigation , 4 Approx.`Depth -A I Eastern —Sulf a Seul Installed_by Repair Work Done Nk- Type of Pump �.dQi^ H.P. _r State Work Oon Well Destruction ❑ Well Diameter sealing Material & Depth Depth Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system per if public sewer is available within 200 feet.l d Installation will serve: Residence, Commercial— Other Number of living units: Number of bedrooms W Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type7Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE: ❑ No. & Length of lines Total length/size S FILTER HED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ii Depth Size Number SUMPS LI istance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County ` T Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r\ employ any person in such manner as to 6ecome subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature j certifies the following; "I certify thatinthe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ,� The appli mu call for all required ' pectio om a drawing on r rse side. a Signed � � Title: aDate: Z�4 IPA ��RA�1"tTMWENT�USE ONLY I: Application Accepted by, Date `��r Area Pit or Grout inspection by Oate Final Inspection by Date / Additional Comments: y 4 Applicant — Return all copies to: San Joaquin County Public Health -Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMfTTED CK RECEIVED BY DATE PERMlT N0. INFO CASH . EH13-21 rHEV.+iw51 WC I-2a EH ZV V G 1